health assessment exam 1 test bank

health assessment exam 1 test bank Related

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A nurse is caring for a patient who has a history of myocardial infarction. The nurse should prioritize which of the following assessments?

  • A. Blood pressure and heart rate.
  • B. Temperature and respiratory rate.
  • C. Bowel sounds and abdominal girth.
  • D. Urine output and skin integrity.
Correct Answer: A

Rationale: The correct answer is A: Blood pressure and heart rate. This is crucial in assessing the cardiac function of a patient with a history of myocardial infarction. Monitoring blood pressure and heart rate helps in evaluating cardiovascular status and detecting any potential complications. Abnormal values in these parameters can indicate inadequate perfusion to the heart or other organs, which can be life-threatening.

Other choices are incorrect because:
B: Temperature and respiratory rate are important assessments but not the priority for a patient with a history of myocardial infarction.
C: Bowel sounds and abdominal girth are more relevant for gastrointestinal issues and not a priority in this scenario.
D: Urine output and skin integrity are important assessments for overall health but do not directly relate to the cardiovascular status in a patient with a history of myocardial infarction.

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Which technique should be used to assess a murmur in a patient's heart?

  • A. The bell of the stethoscope
  • B. The diaphragm of the stethoscope
  • C. Palpation with the palm of the hand
  • D. Ask another nurse to double-check the finding.
Correct Answer: B

Rationale: The correct answer is B: The diaphragm of the stethoscope. The diaphragm is used to assess heart murmurs as it allows for higher-frequency sounds to be heard more clearly. When assessing heart murmurs, using the diaphragm helps to differentiate between systolic and diastolic murmurs, as well as to identify specific characteristics such as intensity and location.

A: The bell of the stethoscope is used for low-frequency sounds and would not be ideal for assessing heart murmurs.
C: Palpation with the palm of the hand is used to assess pulses and vibrations, not heart murmurs.
D: Asking another nurse to double-check the finding is important for validation but does not directly relate to the technique used to assess a heart murmur.

A nurse is caring for a patient with a history of hypertension. The nurse should prioritize which of the following interventions?

  • A. Administering antihypertensive medication as prescribed.
  • B. Encouraging weight loss.
  • C. Monitoring blood pressure regularly.
  • D. Promoting a low-sodium diet.
Correct Answer: A

Rationale: The correct answer is A: Administering antihypertensive medication as prescribed. This is the priority intervention because it directly addresses the patient's hypertension, which is a critical condition that needs immediate management to prevent complications. Encouraging weight loss (B), monitoring blood pressure (C), and promoting a low-sodium diet (D) are all important aspects of managing hypertension. However, administering antihypertensive medication takes precedence as it directly targets lowering blood pressure and reducing the risk of cardiovascular events. Weight loss, monitoring, and dietary changes are important for long-term management but may not provide immediate control of hypertension compared to medication.

Which of the following positions is most appropriate for performing an abdominal examination on an obese patient?

  • A. Head elevated to 45 degrees
  • B. Have the patient lie flat
  • C. Place the patient in the supine position
  • D. Position the patient on their side
Correct Answer: C

Rationale: The correct answer is C: Place the patient in the supine position. This position allows optimal access to the abdomen for examination due to gravitational forces aiding in organ palpation. Having the patient lie flat (choice B) may not provide adequate access. Positioning the patient on their side (choice D) may limit visibility and palpation. Elevating the head to 45 degrees (choice A) is unnecessary for an abdominal examination on an obese patient.

A patient is admitted to the hospital with suspected pneumoniWhat is the first step the nurse should take in the nursing process?

  • A. Diagnosis
  • B. Assessment
  • C. Implementation
  • D. Evaluation
Correct Answer: B

Rationale: The correct answer is B: Assessment. The first step in the nursing process is to assess the patient's condition to gather data and information. In this case, assessing the patient's symptoms, vital signs, and history will help the nurse identify signs of pneumonia and determine the appropriate interventions. Diagnosis (A) comes after assessment, as it involves analyzing the data collected. Implementation (C) and Evaluation (D) are subsequent steps in the nursing process after assessment and diagnosis have been completed. Assessment is crucial for developing an effective care plan and ensuring the best possible outcomes for the patient.

A nurse is caring for a patient who is post-operative following a hip replacement. The nurse should monitor for which of the following complications?

  • A. Pneumonia.
  • B. Deep vein thrombosis (DVT).
  • C. Wound infection.
  • D. Hypoglycemia.
Correct Answer: B

Rationale: The correct answer is B: Deep vein thrombosis (DVT). Post-operative hip replacement patients are at high risk for DVT due to immobility and surgical trauma. The nurse should monitor for signs such as swelling, redness, and pain in the affected leg. DVT can lead to serious complications like pulmonary embolism if not detected early. Choices A, C, and D are incorrect because while pneumonia, wound infection, and hypoglycemia are also potential post-operative complications, they are not as directly associated with hip replacement surgery as DVT.

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